Child Development Screening Checklist
Please complete this checklist to help us assess your child's developmental progress. Your responses will guide further evaluation and support.
Child's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Parent/Guardian Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Screening Checklist: Please indicate your child's current abilities in each area.
*
Rows
Not Yet
Sometimes
Usually
Follows simple directions
1
2
3
Uses words to communicate needs
4
5
6
Walks without assistance
7
8
9
Plays with other children
10
11
12
Feeds self with utensils
13
14
15
How would you rate your child's social skills for their age?
*
1
2
3
4
5
Are there any concerns regarding your child's hearing or vision?
*
No concerns
Yes, hearing
Yes, vision
Yes, both
Please select any areas where you have concerns about your child's development.
Speech/Language
Motor Skills
Social/Emotional
Learning/Cognitive
Behavior
Other
Has your child previously been evaluated for developmental concerns?
Yes
No
Not sure
Additional Comments or Observations
Submit Checklist
Should be Empty: